Patients Were Not Told of Misuse of Syringes

State health officials notified 628 patients this week that they should be tested for hepatitis and H.I.V. infection because they were treated years ago by an anesthesiologist in Nassau County who used improper procedures for preventing the spread of blood-borne diseases.

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The anesthesiologist, Dr. Harvey Finkelstein, of Plainview, first became the focus of a state health investigation in 2005 after two of his patients contracted hepatitis C. His name was reported by Newsday.

Yesterday, county and state officials traded blame over the 34-month delay in notifying the patients. At the same time, the incident led state health officials to seek a meeting with the Centers for Disease Control and Prevention to address an issue of drug packaging that was apparently at the heart of the problem.

In 2005, investigators found that, in violation of widely accepted practices recommended by the C.D.C., Dr. Finkelstein, 52, who specializes in pain management, was reusing syringes when drawing doses of medicine from vials that hold more than one dose.

He would use a new syringe for each patient. But when giving one patient more than one type of drug by injection, his practice of using the same syringe to draw medicine from more than one vial led to the potential contamination of the vials. The blood of a patient who was infected with hepatitis C could, by backing up through the syringe and entering the vials, infect another patient when the same vial of medicine was used again. This is what happened in at least one case, health officials said.

State health officials said yesterday they hoped to get the C.D.C.’s support in seeking the elimination of such multidose vials.

Any fix would come too late for Raymond Bookstaver, 49, a Hicksville mechanic who was one of two patients initially identified as having been infected by Dr. Finkelstein’s improper use of syringes.

“I feel like I went to a doctor for help, and what I got instead was a death sentence,” Mr. Bookstaver said. His hepatitis is being treated, but erupts unpredictably, causing him to suffer flulike symptoms including nausea, vomiting and aching that leaves him bedridden, he said.

At least one and possibly more doctors in the state, including a New York City anesthesiologist, have been reported to state health officials in the last several years for reusing syringes. State officials said they would cite those reports in their meetings with C.D.C. officials.

In 2005, Dr. Finkelstein was instructed in the proper use of syringes in administering pain medications by state health investigators and he has since been monitored to make sure he complied, a State Health Department spokesman said.

For reasons that were unclear yesterday, his case was not referred to the State Board for Professional Medical Conduct of the State Education Department until nine months after his unsafe practices were known.

That agency, charged with taking disciplinary actions against doctors, found no evidence of wrongdoing, and recommended no disciplinary action.

In January 2005, the Health Department began an epidemiological investigation to determine how many of Dr. Finkelstein’s patients were infected by the vials of medicine that he had used more than once.

Investigators notified 98 patients who had received epidural injections for pain management in the three weeks before, during and after Dr. Finkelstein’s two patients were infected, telling them to get tests for blood-borne infections including hepatitis and H.I.V.. Of the 84 who were tested, no other cases of infection were traced to Dr. Finkelstein.

The state then expanded its investigation to cover the years from 2000 to 2005. It was in 2000, Dr. Finkelstein told the investigators, that he began using one syringe to draw doses from numerous vials. In a statement released this week, the state health commissioner, Richard Daines, said “the department identified all 628 patients who had received injections between Jan. 1, 2000, and Jan. 15, 2005, after a thorough review of medical records at all sites where this physician practiced.”

The Nassau County executive, Thomas R. Suozzi, called the long delay in making the notifications “outrageous,” and blamed Dr. Finkelstein and state health officials who he said were overly deferential in their negotiations with the physician’s lawyers.

Claudia Hutton, a spokesman for Commissioner Daines, said that it was routine for the department’s staff to negotiate with a doctor’s lawyers in its investigations, and added: “We worked with Nassau County hand in hand. They were with us all the way. It’s nice that our partners are now playing 20-20 hindsight, but that’s life.”

State health officials acknowledged that the process, begun under the previous health commissioner, could have been more efficient. But they also said that before informing large numbers of patients, they wanted to make sure they only informed those who were at risk of being exposed, to avoid public panic.

“The commissioner wishes it were faster,” said Ms. Hutton, the department spokesman, “and it’s something he’s going to look at and sit down to figure out why the things happened the way they did and how we could have done it more efficiently.”

But, she added, “epidemiological investigations do take a while, and what we had here — it’s not like we found 25 cases within a two-week time frame — we thought we should be cautious.”

But patients and consumer advocates said the delay from January 2005 to November 2007 was a disservice to the public.

Though Mr. Bookstaver’s illness was diagnosed almost immediately by his family doctor, he said that other patients — the 628 notified this week, for example — might not have been as lucky. “What if they have been living with these diseases all this time untreated? And thinking they had the flu?” he said.

Joanne Doroshow, director of the New York-based Center for Justice and Democracy and a member of a state task force on medical malpractice, said the case illustrated “a too-cozy relationship between the medical profession and the people who supposedly regulate them.”

Michael Duffy, a lawyer who specializes in medical malpractice cases and vice president of the New York State Academy of Trial Lawyers, said that the long delay in notifying the 628 potential victims of Dr. Finkelstein’s practice was especially troubling because none would be able to seek damages in court.

2007年11月8日 星期四

Causes of Death Are Linked to a Person’s Weight不同體重群的死因多不同 可能必須重新思考"過胖"想法

About two years ago, a group of federal researchers reported that overweight people have a lower death rate than people who are normal weight, underweight or obese. Now, investigating further, they found out which diseases are more likely to lead to death in each weight group.

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Linking, for the first time, causes of death to specific weights, they report that overweight people have a lower death rate because they are much less likely to die from a grab bag of diseases that includes Alzheimer’s and Parkinson’s, infections and lung disease. And that lower risk is not counteracted by increased risks of dying from any other disease, including cancer, diabetes or heart disease.

As a consequence, the group from the Centers for Disease Control and Prevention and the National Cancer Institute reports, there were more than 100,000 fewer deaths among the overweight in 2004, the most recent year for which data were available, than would have expected if those people had been of normal weight.

Their paper is published today in the Journal of the American Medical Association.

The researchers also confirmed that obese people and people whose weights are below normal have higher death rates than people of normal weight. But, when they asked why, they found that the reasons were different for the different weight categories.

Some who studied the relation between weight and health said the nation might want to reconsider what are ideal weights.

“If we use the criteria of mortality, then the term ‘overweight’ is a misnomer,” said Daniel McGee, professor of statistics at Florida State University.

“I believe the data,” said Dr. Elizabeth Barrett-Connor, a professor of family and preventive medicine at the University of California, San Diego. A body mass index of 25 to 30, the so-called overweight range, “may be optimal,” she said.

Others said there were plenty of reasons that being overweight was not desirable.

Dr. Manson added that other studies, including ones at Harvard, found that being obese or overweight increased a person’s risk for any of a number of diseases, including diabetes, heart disease and several forms of cancer. And, she added, excess weight makes it more difficult to move about and impairs the quality of life.

“That’s the big picture in terms of health outcomes,” Dr. Manson said. “That’s what the public needs to look at.”

Researchers generally divide weight into four categories — normal, underweight, overweight and obese — based on the body mass index, which is a measure of body fat based on height and weight. A woman who is 5 foot 4, for instance, would be considered at normal weight at 130, underweight at 107 pounds, overweight at 150 pounds and obese at 180.

In this study, those with normal weight were considered the baseline and others were compared to them.

The federal researchers, led by Katherine Flegal, of the Centers for Disease Control and Prevention, said the big picture they found was surprisingly complex. The higher death rate in obese people, as might be expected, was almost entirely driven by a higher death rate from heart disease.

But, contrary to expectations, the obese did not have an increased risk of dying from cancer. They were slightly more likely than people of normal weights to die of a handful of cancers that are thought to be related to excess weight — cancers of the colon, breast, esophagus, uterus, ovary, kidney and pancreas. Yet they had a lower risk of dying from other cancers, including lung cancer. In the end, the increases and decreases in cancer risks balanced out.

As for diabetes, it showed up in the death rates only when the researchers grouped diabetes and kidney disease as one category. Diabetes can cause kidney disease, they note. But, the researchers point out, the number of diabetes deaths may be too low because many people with diabetes die from heart disease, and often the cause of death is listed as a heart attack.

The diverse collection of diseases other than cancer, heart disease and diabetes, which show up in the analyses of the underweight and the overweight, have gone relatively unscrutinized among epidemiologists, noted Dr. Mitchell Gail, a cancer institute scientist and an author of the paper. But, Dr. Gail added, “these are not a negligible source of mortality.”

The new study began several years ago when the investigators used national data to look at death risks according to body weight. They concluded that, compared with people of normal weight, the overweight had a decreased death risk and the underweight and obese had increased risk.

That led them to ask if being fat or thin affects a person’s life span, what diseases, exactly, are those individuals at risk for, or protected from?

The research involved analyzing data from three large national surveys, the National Health and Nutrition surveys, which are administered by the National Center for Health Statistics. Their participants are a nationally representative group of Americans who are weighed and measured, assuring that heights and weights are accurate, and followed until death. The investigators determined the causes of death by asking what was recorded on death certificates.

The researchers caution that a study like theirs cannot speak to cause and effect. They do not yet know, precisely, what it is about being underweight, for instance, that increases the death rate from everything except heart disease and cancer. Researchers tried to rule out those who were thin, because they might have been already sick. They also ruled out smokers, and the results did not change.

Dr. Gail, though, had some advice, which, he said, is his personal opinion as a physician and researcher: “If you are in the pink and feeling well and getting a good amount of exercise and if your doctor is very happy with your lab values and other test results, then I am not sure there is any urgency to change your weight.”

2007年11月2日 星期五

Behold the genetically engineered mighty mouse!

In news sure to shiver exterminators everywhere, scientists at Case Western Reserve University have created a super mouse. A mighty mouse! And not just one -- 500 of them! As a result of genetic engineering that boosts the level of an important skeletal muscle enzyme, these little buggers are markedly more active, more aggressive, fitter, and can breed and live longer than ordinary mice.

Whereas a regular rodent can't last an hour on a treadmill -- a cute little mousey treadmill, naturally, not one you find at Gold's -- the super mice can run five or even six hours at 20 meters per minute. An ordinary female mouse can't have any baby mice after she's about a year old, but the mighty mice can reproduce well past age 2.

Richard Hanson, a biochemistry professor who developed the mice with the help of his mousey grad students, offers this quotable quote in a press release: "They are metabolically similar to Lance Armstrong biking up the Pyrenees; they utilize mainly fatty acids for energy and produce very little lactic acid."

The engineered mice have very high levels of an enzyme called phosphoenolpyruvate carboxykinase, or PEPCK-C. Ordinary mice have only 0.08 units of PEPCK-C per gram of skeletal muscle -- super mice have an amazing 9 units per gram.

As a result, their metabolisms are through the roof. And when exercising, super mice rely on fatty acids for their fuel, while ordinary mice use carbohydrates, which raises the level of lactic acid in their blood.

Alas, the researchers say they're not going to do the same thing in humans. "The ethical implications are such that this approach should not be used in humans, or is it technically possible at this time to efficiently introduce genes into human skeletal muscle, in order to mimic the effect seen in our mice," Hanson says. One wonders if the Defense Department feels the same way. (Or maybe the DoD will just use super mice to go after Iran?)

To avoid the Big C, stay small

Nov 1st 2007From The Economist print edition

The best ways to prevent cancer look remarkably like those needed to prevent obesity and heart disease as well

Illustration by Stephen Jeffrey

EVERY day there are new stories in the tabloids about the latest link, sometimes tenuous, sometimes contradictory, between cancer and some aspect of lifestyle. If this is a recipe for confusion, then the antidote is probably a weighty new tome from the World Cancer Research Fund (WCRF). It is the most rigorous study so far on the links between food, physical activity and cancer—and sets out the important sources of risk.

Individually (except for smoking) these risks are quite small. However, many a mickle makes a muckle, and in total they add up to something significant. Roughly speaking, smoking is responsible for a third of cancers (smoking 20 cigarettes a day increases your risk of lung cancer 20-fold), poor food and lack of exercise result in another third, and other causes account for the rest. Some of this last third are known: genetic predisposition, ultraviolet sunlight, pollutants such as pesticides, and other factors including cosmic radiation and a naturally occurring radioactive gas called radon. But the picture is undoubtedly incomplete.

The research has taken six years, involved nine research institutes, and examined more than half a million publications—which were whittled down to 7,000 relevant ones. From these, the new guidelines spring. Few come as news (see table), but the most surprising is the degree to which even being a bit overweight is a risk. One of the most important things a person can do to avoid cancer is to maintain a body mass index (BMI) of between 21 and 23. According to the WCRF's medical and scientific adviser, Martin Wiseman, each five BMI points above this range doubles the risk of post-menopausal breast cancer and colorectal cancer.

For those unfamiliar with BMI, it is calculated by dividing a person's weight in kilograms by the square of his height in metres. Until now, a healthy BMI has been thought of as being between 18.5 and 24.9. The report implies that this range should be narrowed. It is not enough to avoid being clinically obese, or even just a bit overweight. To minimise your risk of cancer, you have to avoid getting fat at all.

Indeed, paying attention to what you eat and drink seems to be the report's watchword. The list is depressingly familiar from injunctions relating to what is coming to be known as metabolic syndrome (obesity, late-onset diabetes, high blood pressure, heart disease and kidney failure, which are starting to look like symptoms of a single, underlying problem). Why cancer and metabolic syndrome might be connected is not yet clear. Cancer is caused by mutational damage to genes that otherwise hold a cell's reproductive cycle in check, and thus stop that cell proliferating. Metabolic syndrome, as its name suggests, seems to be related to the way cells process fats and sugars. There may be no direct link. But it may be that metabolic syndrome involves the production of growth-stimulating molecules that help cancers along.

On the matter of the miscellaneous final third, Devra Davis, an epidemiologist at the University of Pittsburgh and the author of a new book* on cancer, argues that more attention needs to be paid to pollutants and chemical hazards. Few Americans, she says, are aware that the roofs of 35m homes may be insulated with material containing asbestos (which is linked to a cancer called mesothelioma). She observes that a forthcoming report from America's Government Accountability Office will criticise the government for its lack of public warnings about such risks.

There is also concern in America about the overuse of medical X-rays, especially in emergency rooms. Not many people, for example, are aware that computerised tomography (CT) scanning uses large doses of X-rays. A scan of a baby's head is equivalent to between 200 and 600 chest X-rays. However, Dr Wiseman says these risks account for a trivial number of cancers and guesses the remainder are also something to do with nutrition.

Risky business

With hazards everywhere, plus the complications of genetic predisposition and age, it is hard for someone to work out his actual risk of developing either cancer or metabolic syndrome. If that is a recipe for inaction—as it often is—there may be a solution in the form of a personalised health check-up called the PreventionCompass.

This system has been developed by the Institute for Prevention and Early Diagnostics (NIPED), a firm based in Amsterdam. It requires the customer to answer a detailed questionnaire about his way of life and to undergo a series of tests. It draws its conclusions by running the results through a “knowledge system”—a database that pools expertise from many sources.

Coenraad van Kalken, NIPED's founder, says his scientists have programmed in risk factors for cancer, cardiovascular disease, diabetes, kidney disease, lung disease, “burn-out”, depression and other psychological disturbances. The system can, for example, use family history and elevated levels of a particular protein in the blood to work out who should undergo a biopsy to look for prostate cancer. And because it looks at lifestyle as well as biochemistry, it could similarly suggest lower alcohol consumption and a colonoscopy to someone at risk of colorectal cancer.

In the case of this disease, and also breast cancer, such early diagnosis prevents a serious and incurable condition. Bob Pinedo, the director of the Free University medical centre in Amsterdam, told a symposium held by the European School of Oncology in Rome on October 26th that it costs €250,000 ($360,000) to treat (not cure) a patient with late-stage colorectal cancer for 20 months. In the Netherlands, that would pay for 1,000 colonoscopies.

Given the rising costs of dealing with cancer alone—in America this is more than $100 billion a year—prevention and early detection look set to take off. In trials of the PreventionCompass that NIPED conducted last year, more than 75% of the staff of four Dutch companies volunteered to join the scheme. Moreover, occupational-health officers in these companies claim that more than half their staff actually made changes to their way of life as a result. Not bad for a system that costs about €100 a year for each employee.

This year two large insurance companies, which provide corporate health-care, income and disability insurance to employees, are offering to lower the premiums of customers who sign up to the PreventionCompass. Next year, the plan is to extend the scheme more widely, by recruiting Dutch GPs to offer it to people from lower-income groups who do not have such private health insurance.

The message, then, is prevention, not cure. And it is a message that needs to be heeded across the world as poor countries grow wealthier and adopt the eating habits and sedentary lives of the rich. It is an irony that evolution has shaped people to enjoy fat, sugar and indolence—things in short supply to man's hunter-gatherer ancestors, and desirable in the quantities then available. Wealth allows them to be indulged in abundance. Unfortunately, human bodies have evolved neither to cope nor, easily, to resist.

The new rules for defeating cancer

The recommendations include avoiding processed meats such as ham, bacon, salami or any other meat preserved by smoking, curing or salting

Nigel Hawkes, Health Editor

Being even slightly overweight can increase the risk of a range of common cancers including breast, bowel and pancreatic cancer, a landmark study has found.

The largest review of links between diet and cancer, incorporating more than 7,000 studies, concludes that there is convincing evidence that excess body fat can cause at least six different types of the disease. The researchers give warning that everyone should be at the lower end of the healthy weight range.

Their recommendations include avoiding processed meats such as ham, bacon, salami or any other meat preserved by smoking, curing or salting; only consuming small amounts of red meat; moderate consumption of alcohol; and avoiding junk food and sweet drinks.

Professor Sir Michael Marmot, who chaired the expert panel assembled by the World Cancer Research Fund (WCRF) to review evidence on the dietary causes of cancer, said he had been shocked to find that weight was so important.

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A report by the fund published ten years ago linked only one cancer to being overweight. Professor Marmot said the evidence now showed that at least six – cancers of the oesophagus, pancreas, bowel, breast postmenopause, kidney and endometrium (womb lining) – were linked and that the risks were increased by even quite modest weight gains.

The finding is particularly alarming, given the expanding girth of the British population. An official report last month gave warning that by 2050, 60 per cent of men, 50 per cent of women and a quarter of all children could be clinically obese.

A healthy weight is defined as having a body mass index (BMI) below 25; BMI is calculated by dividing an individual’s body weight in kilograms by the square of the height in metres.

Sir Michael said: “A BMI of 25 is fine, but it would be a bit finer if it was lower. The healthiest thing is to be as low as possible within the normal range.” The report suggests moderation in the consumption of red meat, suggesting a limit of 500g (18oz) per person per week. A total avoidance of processed meats is recommended because of convincing evidence that eating meat increases the risk of colon cancer.

The WCRF report emphasises the benefits of exercise, for its direct effects on some cancers, and because it helps to prevent becoming overweight or obese. It made ten recommendations which do not, save in one case, conflict with advice given for the avoidance of other common causes of death, such as heart disease.

The exception is alcohol, which Professor Marmot said had been shown to cut the risk of heart disease. For cancer prevention the optimum level is zero, but for heart disease it is two units a day for men and one for women, he said. The panel agreed that the levels set for minimum heart risk should be accepted.

The report is based on an analysis of cancer studies from around the world dating back to the 1960s. The initial trawl produced half a million studies, which was pared down to the best 7,000. The results were analysed by nine teams and then presented to a panel of twenty-one leading scientists for their recommendations. They looked at cancers at 17 different sites in the body and at a wide range of factors, mostly dietary, that can affect risk of developing the disease.

Professor Marmot said: “We are recommending that people aim to be as lean as possible within the healthy range, and that they avoid weight gain throughout adulthood. This might sound difficult but this is what the science is telling us more clearly than ever. The fact is that putting on weight can increase your cancer risk, even if you are within the healthy range.”

Dairy foods, cheese, butter, coffee and fish get a clean bill of health. But sugary drinks – including fruit juices – can increase weight and are therefore not recommended. Nor are fast foods because they are energy-dense and lead to excess weight or obesity, which in turn increase cancer risks.

Professor Martin Wiseman, the project director, said: “This report’s recommendations represent the most definitive advice on preventing cancer that has ever been available anywhere in the world.”

Breast-feeding has a double benefit, the report says, protecting mothers against breast cancer and their babies against obesity. Mothers were advised to breastfeed exclusively for six months and to continue with complementary breastfeeding after that.

Dietary supplements for cancer prevention were not recommended, since there was evidence that at high doses they could have adverse effects. But selenium, in the diet or as a supplement, did appear to have benefits against lung, colon and prostate cancer.

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Professor Mike Richards, the Government’s clinical director of cancer, said: “The WCRF report is the most authoritative and exhaustive review done thus far on the prevention of cancer through food, nutrition and physical activity. For those of us wanting to lower our risk of developing cancer, it provides practical lifestyle recommendations.”

Karol Sikora, Professor of Cancer Medicine at Imperial College School of Medicine, said: “The educational message for the public should be that there are healthy diets and unhealthy diets, but we should keep everything in perspective and not suggest rigid avoidance. Alcohol, red meat and bacon in moderation will do us no harm, and to suggest it will is wrong.”

Chris Lamb, consumer marketing manager at the British Pig Executive, said that people should continue to eat bacon “in a responsible way as part of a balanced diet”. Cancer was a “complicated subject” and could not be prevented simply by reducing intake of meat.

“Two thirds of all cancers are not caused by diet. Just by addressing the meat issues, you are not necessarily going to prevent cancer,” he said.

Mr Lamb said that the average consumption of red meats was less than 500 grams per week in any case, so many people did not need to change their eating habits at all.

He added that there were concerns amongst farmers that sales of processed meats could fall as a result of the report. “That is obviously a potential at the end of the day, but we’re hoping that consumers will think about being responsible in overall terms.”

The ten WCRF recommendations:

Be as lean as possible within the normal range of body weight

Be physically active as part of everyday life

Limit consumption of energy-dense foods, and avoid sugary drinks

Eat mostly foods of plant origin

Limit intake of red meat and avoid processed meat

Limit alcoholic drinks

Limit consumption of salt, and avoid mouldy cereals or pulses

Aim to meet nutritional needs through diet alone

If a new mother, breastfeed your baby

Cancer survivors should follow the recommendations for cancer prevention

Americans are increasingly frustrated about the subpar performance of this country’s fragmented health care system, and with good reason. A new survey of patients in seven industrialized nations underscores just how badly sick Americans fare compared with patients in other nations. One-third of the American respondents felt their system is so dysfunctional that it needs to be rebuilt completely — the highest rate in any country surveyed. The system was given poor scores both by low-income, uninsured patients and by many higher-income patients.

The survey, the latest in a series from the Commonwealth Fund, is being published today on the Web site of Health Affairs, a respected health policy journal. Researchers interviewed some 12,000 adults in Australia, Canada, Germany, the Netherlands, New Zealand, the United Kingdom and the United States.

Given the large number of people uninsured or poorly insured in this country, it was no surprise that Americans were the most likely to go without care because of costs. Fully 37 percent of the American respondents said that they chose not to visit a doctor when sick, skipped a recommended test or treatment or failed to fill a prescription in the past year because of the cost — well above the rates in other countries.

Patients here were more likely to get appointments quickly for elective surgery than those in nearly all the other countries. But access to primary care doctors, the mainstay of medical practice, was often rocky. Only half of the American adults were able to see a doctor the same day that they became sick or the day after, a worse showing than in all the other countries except Canada. Getting care on nights and weekends was problematic.

Often the care here was substandard. Americans reported the highest rate of lab test errors and the second-highest rate of medical or medication errors.

The findings underscore the need to ensure that all Americans have quick access to a primary care doctor and the need for universal health coverage — so that all patients can afford the care they need. That’s what all of the presidential candidates should be talking about.